Screening of Gestational and Hypertension Among Antenatal Women in Rural West

Viral R. Dave1, Bhavik M. Rana1, Kantibhai N. Sonaliya1, Suraj J. Chandwani2, Samkit V. Sharma2, Swati O. Khatri2, Khalid M. Shaikh2, Farida M. Hathiari2

1Community Department, Gujarat Cancer Society (GCS) Medical College, Ahmedabad, Gujarat, India; 2Gujarat Cancer Society (GCS) Medical College Hospital & Research Centre, Ahmedabad, Gujarat, India

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Abstract

Background: Hypertension and gestational diabetes are among the leading causes of maternal and perinatal mortality, especially in rural areas of developing countries with meager health facilities. With early diagnosis and timely treatment, these adverse events can be decreased. The primary aim of this study was to implement a screening program for gestational diabetes and hypertension, and to assess risk factors associated with these conditions among antenatal women in the rural area of the Gujarat province in India. Methods: A cross–sectional study was conducted at one of the rural areas of Gujarat province in India. Following a random cluster sampling procedure, the village of Davas was selected. A multistage random sampling method was utilized, resulting in a sample of 346 antenatal women. Screening guidelines from the American Diabetes Association were followed for gestational diabetes screening. Results: The majority of antenatal mothers (55.50%) were between 21-25 years of age. 242 antenatal women were multigravida, and among them, 85.96% had institutional delivery at their last pregnancy. Of the total 346 women, 17.60% were prehypertensive. The prevalence of systolic hypertension was 1.40%, diastolic hypertension was 0.90%, and gestational diabetes was 1.73%. Conclusion: Socioeconomically upper class, a family history of hypertension, and BMI ≥ 25 were strong risk factors for hypertension during pregnancy and gestational diabetes. Health education should be made readily available to antenatal mothers by paramedical workers regarding symptoms of hypertension and gestational diabetes mellitus for early self identification.

Keywords: gestational diabetes, hypertension, screening, maternal mortality, perinatal mortality

Screening of Gestational Diabetes Research and Hypertension Among Antenatal Women in Rural West India Maternal mortality and perinatal mortality are two very important indicators of the developmental index of a country and have a significant impact on the Viral R. Dave1, Bhavik M. Rana1, population’s life expectancy. Hypertension (HTN) during pregnancy/pre-eclampsia and gestational diabetes Kantibhai N. Sonaliya1, Suraj J. are among the leading causes of maternal and perinatal 2 2 Chandwani , Samkit V. Sharma , morbidity and mortality, especially in rural areas of 2 2 Swati O. Khatri , Khalid M. Shaikh , developing countries.1,2 Farida M. Hathiari2 The literature suggests that 10-15% of maternal 1Community Medicine Department, Gujarat mortality in developing countries is due to hypertensive Cancer Society (GCS) Medical College, disorders of pregnancy.3,4 Various adverse effects of Ahmedabad, Gujarat, India; 2Gujarat Cancer HTN in pregnancy include preterm delivery, intrauterine Society (GCS) Medical College Hospital & growth retardation, reduced birth weight, still birth, and Research Centre, Ahmedabad, Gujarat, perinatal mortality.5,6 Early detection and prompt care are India required to prevent adverse outcomes of pregnancy with HTN. For this reason, it is recommended to evaluate a

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH

woman’s risk for HTN at their first prenatal visit. In Centre, Ahmedabad, India, the present study was India, the National Health Programme of Reproductive conducted at one of the rural areas of the Gujarat and Child Health has stipulated routine screening of province in India. The study was conducted between blood pressure (BP) for antenatal mothers at each visit, March 2013 and June 2013 and utilized cross-sectional which should be implemented in conjunction with the assessments. A multistage random cluster sampling assessment of maternal history of HTN symptoms. method was utilized to obtain a sample of 346 antenatal women. After preparing a list of districts of Gujarat state Prevalence of gestational diabetes mellitus in their ascending order as per their population, the (GDM) in some ethnic groups ranges from 1 to 14% Banaskantha district was randomly selected. Following depending on screening method selection, diagnostic random selection procedure, the taluka “Deesa” criteria, and population screened. GDM can negatively (administrative subunit of district) and the village of affect pregnancy and result in adverse perinatal outcomes “Davas” were selected. such as macrosomia, birth trauma, shoulder dystocia, and higher rates of Cesarean section.7 In India, screening is The Primary Health Centre (PHC) is a very essential in all pregnant women, as Indian women have basic medical setting, which provides services an eleven-fold increased risk8 of developing glucose to rural populations. The PHC of Davas was contacted to intolerance during pregnancy compared to Caucasian ascertain a list of “” discovered in the field women,9 which can be decreased with early screening, practice area of PHC. Anganwadi is a part of the Indian diagnosis, and treatment. It is generally accepted that public health-care system where basic health-care women of Asian origin, especially ethnic Indians, are at activities are carried out for antenatal and postnatal a higher risk of developing GDM and subsequently type women, adolescent girls, and children less than 6 years 2 diabetes.10,11 The so-called Asian-Indian phenotype of age. PHC in Davas covers a total population of 39,001 refers to certain unique clinical and biochemical people and 15 other villages around Davas, as per the abnormalities in Indians, which includes, but is not 2011 census. Anganwadi centers are a basic unit of the limited to, increased insulin resistance and greater Integrated Child Development Scheme run by the abdominal adiposity. This phenotype makes Indians and provide health care services to more prone to diabetes.12 antenatal and postnatal women, adolescent girls, and children less than 6 years of age. Monthly prenatal check The objective of this study was to implement ups is one of the key health services provided by these screening for gestational diabetes and HTN and to centers. A total of 346 antenatal women were registered investigate risk factors associated with the development with all covered by Davas PHC. All were of these conditions among women in Gujarat province in interviewed and after informed consent was taken from India. The ultimate goal of this work was to minimize each participant, they were included in the study. A complications and reduce morbidity and mortality pretested and structured questionnaire on socio- associated with gestational diabetes and HTN in high- demographic information, obstetric details, and outcome risk groups. of screening tests was used for data collection. Various risk factors generally associated with gestational diabetes Methodology and HTN such as age, BMI (body mass index), education, occupation, socioeconomic class, and family history After obtaining permission from the were also assessed using questionnaires. Institutional Ethical Committee at Gujarat Cancer Society (GCS) Medical College, Hospital & Research

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The modified Prasad classification13 was used mothers (55.50%) were 21-25 years of age. It is for socioeconomic stratification, which is commonly noteworthy that 21.10% of pregnant women were ≤ 20 used on the Indian subcontinent. This classification years of age while 2.89% of participants were > 30 years system divides the community into five different classes aged. 60.98% of expectant mothers were illiterate, and based on per capita income of family and taking into only 0.87% had education at secondary school level, consideration All India Consumer Price Index declared while none of them had completed any secondary by the Labour Bureau, Government of India at the time education. Most of participant females were housewives of study.14 (63.58%), while 34.97% of mothers were engaged in strenuous labor activities such as farming, construction, For screening of gestational diabetes, guidelines etc. Based on modified Prasad classification for of American Diabetes Association15 were followed, socioeconomic class, the majority of women belonged to which state that: a fasting plasma glucose level > 126 lower socioeconomic classes. 39.60% of women were mg/dl (7.0 mmol/l) or casual plasma glucose > 200 mg/dl from class IV and 42.77% belonged to socioeconomic (11.1 mmol/l) meets the threshold for diagnosis of class V. 7.23% of antenatal women had a BMI ≥ 25. diabetes, if confirmed on a subsequent day and precludes need for any glucose challenge. Following the above- mentioned guidelines, random blood sugar levels (RBS) Table 1: Baseline characteristics of study participants were measured using a standard glucometer (Glucosign @ Accubiotech). Participants with RBS > 200 mg/day were re-screened on the following day with a fasting Table 2 describes obstetric profiles of study blood sugar. participants. 69.94% of antenatal women were Blood pressure was classified per the following multigravida, while 30.06% were primigravida. In criteria:16 normal if < 120 systolic BP and < 80 diastolic multigravida participants, most deliveries were BP, prehypertension if 120-139 systolic BP or 80-89 institutional (85.96%) while 14.04% of mothers had their diastolic BP, Stage I HTN if 140-159 systolic BP or 90- last delivery without medical supervision. Of this 14.04% 99 diastolic BP, and Stage II HTN if systolic BP ≥ 160 or of mothers, the majority had home delivery; however, diastolic BP ≥ 100. A standard sphygmomanometer was some delivered at their work place, including farms. used to measure BP. All BP measurements were taken in 11.57% had their deliveries conducted by traditional birth sitting position, and on finding BP higher than normal, a attendants (TBA) known as “dai” in India, while 2.47% recording was repeated immediately and also on the next of deliveries were conducted by other attendants day to ensure that measurements were accurate. (including relatives, neighbors, and quacks). Conservative recording of the lowest reading was evaluated in the data analysis. Data entry and data analysis were performed using SPSS software. Risk Table 2: Obstetric profile of study participants factors for HTN and diabetes were analysed by bi-variate analysis along with the use of odds ratios. Figure 1 shows the distribution of BP among antenatal women in the study at screening. It suggests Results that 80.90% of study participants had systolic BP within normal range, while 17.60% were prehypertensive. Table 1 presents sociodemographic data of 1.20% and 0.20% had stage I and stage II systolic BP study participants at baseline. The majority of antenatal HTN, respectively. Diastolic BP distribution was

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somewhat different. 90.80% had normal diastolic BP. Discussion 8.40% were prehypertensive, while 0.60% and 0.30% The present study found the prevalence of had stage I and II diastolic BP HTN, respectively. systolic HTN was 1.40%, diastolic HTN was 0.90%, and GDM was 1.73%. Upper socioeconomic class and positive family history of HTN were significantly Figure 1: Distribution of stages of hypertension among associated with HTN. While analyzing other risk factors, antenatal women at screening only BMI ≥ 25 was significantly associated with GDM among study participants.

Table 3 suggests the role of various risk factors A study conducted by Yadav et al.17 found a associated with HTN, using odds ratio based on bi- prevalence of HTN as high as 8.70% among females of variate analysis. The risk factors evaluated were age, less than 40 years of age. However, the sample included BMI ≥ 25, lower socioeconomic class, occupation, females from an urban colony of high-income residents education and family history positive for HTN. Upper among the general population, which could be socioeconomic class and positive family history of HTN responsible for the high prevalence. While the were significantly (p < 0.05) associated with HTN among government is expending a considerable amount of funds study participants. as well as manpower to decrease maternal and perinatal mortality, it appears that residents of remote rural and tribal areas may not be taking advantage of some of the Table 3: Odds ratio for risk factors found to be associated screening and early diagnosis practices. with systolic hypertention The overall prevalence of diabetes in the western region of India was found to be 3.70%;18 Random blood sugar levels were checked for however, in this study, all age groups as well as all screening of GDM as per guidelines mentioned in genders were included in this study. A previous study19 methodology. The screening yielded 1.73% antenatal conducted in Punjab region of India showed a prevalence mothers had their RBS levels more than 200 mg/dl on of systolic HTN at 4.45% and diastolic HTN at 4.20% in two occasions. None of them were known cases of a sample of 1,000 pregnant females, while the present diabetes, while 98.27% had their RBS within normal study found a prevalence of systolic HTN was only range. 1.40% and diastolic HTN was 0.90%. The differences between this study and the above mentioned study could The role of various risk factors associated with be attributed to a larger sample size from both rural and gestational diabetes, using odds ratio based on bi-variate urban areas of the Punjab state used in the previous study. analysis is described in Table 4. It shows that among various risk factors such as age, BMI ≥ 25, upper Sayeed et al.20 found in their study at socioeconomic class, occupation, education, and family Bangladesh a crude prevalence of systolic and diastolic history of HTN, only a BMI of ≥ 25 was significantly (p HTN was 6.80% and 5.40%, respectively, possibly due < 0.05) associated with GDM among study participants. to the inclusion of a higher aged sample. Bener and Saleh21 in their study at Qatar found maternal age > 30,

increased BMI, previous abortion, lack of antenatal care, Table 4: Odds ratio for risk factors found to be associated and physical activity were significantly associated with with gestational diabetes an increased risk of Pregnacy Induced Hypertension

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(PIH). In the current study, upper socioeconomic class In the same study, Rajput et al.24 found that 8.20% of and positive family history of HTN were found to be participants had a BMI ≥ 25 while in current study it was associated with HTN, which is comparable to other 7.20%. similar studies.20,21

In the present study, the prevalence of GDM Limitations of the Study was found to be 1.73%. Kalra et al.22 found a prevalence of GDM among the study population was 6.60%, while This investigation had one main limitation. Though Gupta et.al.23 in the Jammu region of India found a most research recommends Oral Glucose Tolerance Test prevalence of GDM was 3.05%. These data reveal a wide (OGTT) as a method of choice for screening of diabetes, variation in the prevalence of gestational diabetes in this method was not possible to implement in the context India. A previous study24 conducted in Haryana, North in this study. OGTT is supposed to be performed under India, showed 7.10% prevalence, while another study25 clinical observation with laboratory set up. It also conducted in South India revealed prevalence of 17.80% requires multiple blood draws for which the subject needs women in urban, 13.80% in semi urban, and 9.90% in to be contacted more than 2 times and requires longer rural population of gestational diabetes. Sayeed et al.20 in time duration (3-4 hours). As the current study is a cross Bangladesh found the prevalence of diabetes was 6.80% sectional study with limited resources at remote rural according to fasting blood glucose (FBG) guideline area, the necessary time, human resource and financial values. In the present study, we found that only BMI ≥ resources were limiting factors for conducting GTT. 25 was significantly associated with GDM, while Sheshiah et al.25 found that age ≥ 25 years, BMI ≥ 25 kg/m2, and positive family history of diabetes were Strengths of the Study significantly associated with GDM. Rajput et al.24 found As there are very limited number of studies that socioeconomic status above upper middle class and conducted in the past involving pregnant women of rural Kalra et al.22 found that family history of diabetes India, this study can contribute significantly and provide mellitus, age ≥ 25 years, past history of GDM, and BMI a glimpse about health conditions of antenatal women in ≥ 25 kg/m2 were significantly associated with GDM rural population of India. The current study also provided group. Rajput et al.24 found that socioeconomic status an opportunity to contact study subjects and identify above upper middle class was associated significantly some previously undetected at risk women who were with GDM in their findings. Kalra et al.22 found that a referred for further evaluation and management. family history of diabetes mellitus, age ≥ 25 years, past history of GDM, and BMI ≥ 25 kg/m2 were significantly associated with GDM group in their study. Conclusion & Recommendations 55.49% of participants in the present study were The present study found prevalence of systolic 21-25 years of age, and 60.98% were illiterate. In a HTN was 1.40%, diastolic HTN was 0.90%, and GDM similar study by Rajput et al.24 58.20% were 21-25 years was 1.73% among study population in the rural area of of age, while only 4.90% were illiterate. Literacy rate in Gujarat province, India. Overall, the prevalence of the present study was low as compared to national gestational diabetes and HTN in the Gujarat state should average (65.46%) and Gujarat state average (70.73%) for be evaluated in the future with a multicenter study and females.26 The reason may be due to the fact that the larger sample size. Incidence and prevalence rate of any selected district was in a remote area with tribal vicinity. specific is the basis for making prevention

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strategies at national level of health planning. A proper 9. Wahi P, Dogra V, Jandial K, et al. Prevalence of gestational disease registry should be created for monitoring diabetes mellitus (GDM) and its outcomes in Jammu region. J Assoc Physicians India. 2011;59:227-230. gestational diabetes and pregnancy induced HTN. Public health education should be made readily available to 10. Dornhorst A, Paterson CM, Nicholls JS, et al. High prevalence of gestational diabetes in women from ethnic minority antenatal mothers by paramedical workers regarding groups. Diabet Med. 1992;9(9):820-825. alarming symptoms of HTN and GDM for early self 11. Seshiah V, Sahay BK, Das AK, et al. Diagnosis and identification. Adopting a healthy life style and management of gestational diabetes mellitus: Indian guidelines. monitoring blood pessure and sugar levels are keys for 2013; prevention of HTN and diabetes in India and globally. http://www.apiindia.org/medicine_update_2013/chap44.pdf. Accessed October 4, 2014.

12. Magon N. Gestational diabetes mellitus: Get, set, go From Conflict of Interest diabetes capital of the world to diabetes care capital of the world. Indian J Endocrinol Metab. 2011;15(3):161-169.

The authors report no conflict of interest. 13. Agarwal A. Social classification: The need to update in the present scenario. Indian J Community Med. 2008;33(1):50-51. 14. Labour Bureau, Government of India. Statistics. 2014; References http://labourbureau.nic.in/indtab.html. Accessed October 4, 2014. 1. World Health Organization (WHO). Maternal mortality. 2014; http://www.who.int/mediacentre/factsheets/fs348/en/. 15. American Diabetes Association. Position statement, Accessed June 25, 2012. gestational diabetes mellitus: Diabetes care. 2004.

2. Otolorin EO, Famuyiwa OO, Bella AF, Dawodu AH, Adelusi 16. Kotchen TA. Hypertensive Vascular Disease. Harrison’s B. Reproductive performance following active management of principals of internal medicine. 17th ed. United States: The diabetic pregnancies at the University College Hospital, Ibadan, McGraw-Hill Companies; 2008. Nigeria. Afr J Med Med Sci. 1985;14(3-4):155-160. 17. Yadav S, Boddula R, Genitta G, et al. Prevalence & risk 3. Al-Ghamdi SM, Al-Harbi AS, Khalil A, El-Yahyia AR. factors of pre-hypertension & hypertension in an affluent north Hypertensive disorders of pregnancy: Prevalence, classification Indian population. Indian J Med Res. 2008;128(6):712-720. and adverse outcomes in northwestern Saudi Arabia. Ann Saudi Med. 1999;19(6):557-560. 18. Mohan V, Pradeepa R. Epidemiology of diabetes in different regions of India. Health Administrator. 2009;22:1-18. 4. Mounier-Vehier C, Delsart P. Pregnancy-related hypertension: A cardiovascular risk situation. Presse Med. 19. Gupta S, Gupta V, Bakshi D, Madaan U, Meshwari R, 2009;38(4):600-608. Yashpal J. To study the prevalence of hypertension and pre- hypertension and their correlation with age, number of 5. Yadav S, Saxena U, Yadav R, Gupta S. Hypertensive pregnancies, duration of pregnancy, body mass index, fasting disorders of pregnancy and maternal and foetal outcome: A case blood sugar and hemoglobin in pregnant females in Punjab. controlled study. J Indian Med Assoc. 1997;95(10):548-551. 2008; http://www.japi.org/april2008/Oral_Hypertension.htm Accessed August 12, 2013. 6. Jain L. Effect of pregnancy-induced and chronic hypertension on pregnancy outcome. J Perinatol. 20. Sayeed MA, Mahtab H, Khanam PA, Begum R, Banu A, 1997;17(6):425-427. Azad Khan AK. Diabetes and hypertension in pregancy in a rural community of Bangladesh: A population-based study. Diabet 7. Gasim T. Gestational diabetes mellitus: Maternal and Med. 2005;22(9):1267-1271. perinatal outcomes in 220 saudi women. Oman Med J. 2012;27(2):140-144. 21. Bener A, Saleh NM. The impact of socio-economic, lifestyle habits, and in developing of pregnancy-induced 8. Neelakandan R, Sethu PS. Early universal screening for hypertension in fast-growing country: Global comparisons. Clin gestational diabetes mellitus. J Clin Diagn Res. 2014;8(4):OC12- Exp Obstet Gynecol. 2013;40(1):52-57. OC14.

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22. Kalra P, Kachhwaha CP, Singh HV. Prevalence of tertiary care hospital in Haryana. Indian J Med Res. gestational diabetes mellitus and its outcome in western 2013;137(4):728-733. Rajasthan. Indian J Endocrinol Metab. 2013;17(4):677-680. 25. Seshiah V, Balaji V, Balaji MS, et al. Prevalence of 23. Gupta A, Gupta YV, Kumar S, Kotwal R. Screening of gestational diabetes mellitus in South India (Tamil Nadu)--A gestational diabetes mellitus with glucose challenge test in high community based study. J Assoc Physicians India. 2008;56:329- risk group. Journal of Medical Education and Research. 333. 2006;8(2). 26. State of literacy. http://censusindia.gov.in/2011-prov- 24. Rajput R, Yadav Y, Nanda S, Rajput M. Prevalence of results/data_files/india/Final_PPT_2011_chapter6.pdf. gestational diabetes mellitus & associated risk factors at a

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Table 1: Baseline characteristics of study participants from the Davas village

Characteristics Number of Participants (%) Age (years) ≤ 20 73 (21.10) 21 – 25 192 (55.49) 26 – 30 71 (20.52) 31 – 35 9 (2.60) ≥ 36 1 (0.29) Education Illiterate 211 (60.98) Primary 132 (38.15) Secondary and above 3 (0.87) Occupation Housewife 220 (63.58) Laborer 121 (34.97) Other 5 (1.45) Socioeconomic class I 3 (0.87) II 18 (5.20) III 40 (11.56) IV 137 (39.60) V 148 (42.77) BMI (Kg/M2) < 18.5 68 (19.65) 18.5 – 25 253 (73.12) ≥ 25 25 (7.23)

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Table 2: Obstetric profile of study participants

Characteristics Number of Participants (%) Gravida Primigravida 104 (30.06) Multigravida 242 (69.94) Last delivery conducted (n = 242) Institutional deliveries 208 (85.96) Traditional birth attendants 28 (11.57) Other 6 (2.47) Mode of last delivery (n = 242) Full term normal delivery 202 (83.47) Premature delivery 7 (2.89) Miscarriage 2 (0.83) Abortion 27 (11.16) Cesarian section 4 (1.65)

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Table 3: Odds ratio for risk factors found to be associated with systolic hypertension

95% Confidence interval Risk factors Odds ratio Lower Upper p-value Age > 25 years 0.81 0.08 7.37 0.60 BMI ≥ 25 3.29 0.35 30.62 1.25 SE Upper Class (I + II)* 7.77 1.27 47.60 0.03 Housewife 0.14 0.01 1.26 0.13 Education (Illiterate) 0.15 0.01 1.41 0.08 Family history* 2.89 0.32 25.83 0.02 Note. * denotes significance with a p < 0.05.

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Table 4: Odds ratio for risk factors found to be associated with gestational diabetes

95% Confidence interval Risk factors Odds ratio Lower Upper p-value Age > 25 years 1.66 0.30 9.26 0.38 BMI ≥ 25* 5.36 0.53 53.94 0.01 SE Upper Class (I + II) 1.53 0.73 3.21 0.46 Housewife 1.14 0.20 6.35 0.28 Education (Illiterate) 1.29 0.23 7.14 0.81 Family history 1.78 0.27 8.13 0.09 Note. * denotes significance with a p < 0.05.

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Figure 1: Distribution of stages of hypertension among antenatal women at screening

100 90.8 90 80.9 80

70

60

50 Systolic Diastolic 40

30

20 17.6 8.4 10 Percantagedistribution studyof participants 1.2 0.6 0.2 0.3 0 Normal Prehypertensive Stage I Stage II

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